Basic Physical Assessment Headtotoe assessment Major body systems assessment

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Basic Physical AssessmentHead-to-toe
assessmentMajor body systems assessment
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Purpose

• Gather baseline data
• Supplement, confirm, or refute data in nursing hx
• Confirm and identify nursing diagnosis
• Make clinical judgments about changing status
• Evaluate the physiological outcomes of care

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Health History

• Provides baseline subjective information
• Guides and directs your physical assessment
• Identifies
• Strengths
• Actual or potential health problems
• Support system
• Teaching needs
• Discharge and referral needs
• Use of effective communications skills

• Family history
• Life patterns
• Sociocultural history
• Spiritual health
• Mental reactions
• Emotional reactions

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PHYSICAL ASSESSMENT

• Validates the patients complaints related to
  health
• Assists in formulating nursing diagnoses and
  interventions
• Monitors current health problems
• Obtains baseline information for future
  assessments

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Assessment techniques

• Inspection Always first!!!
• Palpation
• Percussion
• Auscultation

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Assessment techniques Palpation

• Temperature
• Texture
• Moisture
• Organ size and location
• Rigidity or spasticity

• Crepitation, Vibration
• Position
• Size
• Presence of lumps or masses
• Tenderness, or pain

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Assessment techniques Percussion

• Assess underlying structures for location, size,
  density of underlying organs.
• Direct sinus tenderness
• Indirect- lung percussion
• Blunt percussion- organ tenderness (CVA
  tenderness)

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Assessment techniques Percussion sounds

• Flatness bone or muscle
• Dullness heart, liver, spleen
• Resonance air filled lungs (hollow)
• Hyperresonance emphysematous lung
  (hyperinflated)
• Tympany air-filled stomach (drumlike)

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Assessment techniques Auscultation

• Listening to sounds produced by the body
• Heart
• Blood vessels
• Lungs
• Abdomen
• Instrument stethoscope
• Diaphragm high pitched sounds
• Bell low pitched sounds

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Assessment techniques Auscultation

• Avoid Interruptions
• Start with a general inspection first
• Proceed for specific observation of the system
• Expose only the part being examined

• Examine the unaffected area or parts first
• Examine external parts first, then internal
• Compare one side to the other side
• Proceed from head to toe

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Eyes - PERRLA

• Shine light through pupil onto retina
• Cranial nerve III stimulated
• Observe for pupillary constriction
• Observe for accomodation
• Pupils black, round, regular, equal in
  size, 3-7 mm
• PERRLA Pupils equal, round, reactive to light,
  accommodation

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Pupils

• Cloudy pupil cataracts
• Dilated pupil glaucoma, trauma, neurologic
  disorder
• Constricted pupil drug use
• Pinpoint pupil opioid intoxication

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Great vessels of the neck

• Jugular veins
• Empty unoxugenated blood directly into the
  superior vena cava, which empties into the right
  side of the heart
• Carotid arteries
• Reflects cardiac systole and is timed with S1,
  Palpate only one at a time
• Carotid artery pulse correlates with first
  heart sound

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Assessment

• Position client supine
• Then head elevated at 45 degrees
• INSPECTION
• Lifts, heaves
• PMI (assess location)

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GeneralReference Lines

• Sternal Line
• Midclavicular Line
• Apical /PMI left 5 th iCS midclavicular line
• Axillary Line

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Heart Auscultatory Sites

• When auscultating sounds, place the stethoscpe
  over the four different site
• All physicians take money- APTM
• Aortic, Pulmonic, Trisuspic, Mitral
• The sites are identified by the names of heart
  valves but they are not located directly over
  the valves.
• Rather, these sites are located along the pathway
  blood takes as it flows throught the hearts
  chambers and valves.

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Heart

• Review heart is in the center of the chest,
  behind and to left of the sternum
• Base is at top, apex is the bottom tip
• Apex touches anterior chest wall at 5th
  intercostal space medial to left midclavicular
  line
• Heart pumps blood through 4 chambers
• Events on left side occurs just before those on
  right
• Valves open and close, pressures within rise and
  fall and chambers contract as blood flows though
  each chamber

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Cardiac Cycle

• Systole ventricles contract and eject blood
  from left ventricle into aorta and from right
  ventricle into pulmonary system
• Diastole ventricles relax and atria contract to
  move blood into ventricles and fill coronary
  arteries
• Diahragm of the stethoscpe for
  highpitched sounds heart sounds
• Bell- for low pitched sounds bruits, murmurs

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Heart Sounds

• S1 Lub mitral valve closure
• S2 Dub Aortic valve closure

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Heart Sounds S1 S2

• S1
• Closure of mitral and tricuspid valves (M1
  before T1)
• Correlates with the carotid pulse
• Can be split but not often

• S2
• Closure of aortic and pulmonic valves
• May have a split sound (A2 before P2)

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Heart Sounds

• S1 loudest at the apex (tricuspid), this sound
  corresponds to the closure of M1 T1
• May be split.
• S2 loudest at the base (aortic),
• Physiologic S2 splitting- heard best at pulmonic
  area during peak inspiration
• S2 splitting when the pulmonic valve closes
  later than the aortic valve normal during
  inspiration
• Fixed split ASHD no variation with insp.

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Extra Heart Sounds- S3

• a low-pitch vibration in early diastole
  immediately after S2
• Rapid ventricular filling ventricular gallop
  May be a cardinal sign of CHF in adults
• May be normal in children, and patients with high
  cardiac output (athletes)
• Pathological in adults CHF, HTN, CAD
• S1 -- S2-S3
• Sounds like Ken--tuc-ky

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Extra Heart Sounds- S4

• Soft, low-pitched sound in late diastole
  immediately before S1
• Atria contract and eject blood into resistant
  ventricles (slow ventricular contraction) atrial
  gallop
• May be physiological in infants and small
  children
• Common in HTN pts
• S4-S1 S2
• Sounds like Ten-nes--see

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Heart Sounds

• Normal (Lub-dub, Lub-dub)
• S1 Lub (Closure of AV Valves at start of systole)
• S2 Dub (Closure of pulmonic and aortic valves
  upon end diastole)
• 3rd Heart Sound Middle 3rd of diastole
• 4th Heart Sound Atrial

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S1 Systole S2
Diastole S1 Systole S2

S4
S3
S4
M
T
A
P
M
T
A
P
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Peripheral Pulses

• Apply firm pressure with pads of index and middle
  finger on pulse site without occluding pulse
• Measure strength of pulse and equality
• Assess carotid, radial, and pedal
• Also assess brachial, posterior tibial, and
  dorsalis pedis

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Peripheral Pulses

• Apply firm pressure with pads of index and middle
  finger on pulse site without occluding pulse
• Measure strength of pulse and equality
• Assess carotid, radial, and pedal
• Also assess brachial, posterior tibial, and
  dorsalis pedis

• Documentation of Pulses

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Grading

• 0 Absent, not palpable
• 1- Diminished, barely palpable
• 2- Easily palpable, normal pulse
• 3 - Full pulse, increased
• 4 - Strong, bounding, cannot be obliterated

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Lower Extremities

• Pedal pulses
• Foot strength bilaterally
• Homans Sign
• Capillary refill (see next slide)
• Edema
• Pain

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Capillary Refill

• Should test fingers and toes
• Press down on nail to compress capillaries
• Color goes white, then release
• Color should return briskly lt 3 seconds
• Document sluggish if gt 3 seconds

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Assessing for Edema

• Depress
• pretibial area medial malleolus for 5 seconds
• Grade pitting edema
• 1 to 4

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Lungs Anatomy and Landmarks

• Lungs are paired but not symmetrical (see next
  slide)
• right lung 3 lobes RUL, RML, RLL
• left lung2 lobes LUL , LLL
• Lung border locations
• Apices 1 inch above the clavicles
• Bases located at the level of the 6th rib
  (T10)
• Lateral chest extend from the apex of the
  axilla to the 7th or 8th rib.

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Lungs

• Inspection
• Color, Size and shape of chest, any deformities
  or lesions
• Resp. rate and depth
• Pattern of respiration regular rhythm
• Abnormal patterns
• Hyperventilation-fast rate and deep breathing
• Tachypnea gt28 vs. bradypnea lt10
• Stertorous -death rattle seen in comatose
  patient

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Lungs

• Inspection
• Check size, shape, symmetry
• Altered shape ex., COPD, barrel chest
• Altered symmetry ex., kyphosis (hunchback),
  scoliosis (S)
• Altered breathing ex., rib fractures,
  pneumothorax
• Altered color ex., hypoxia
• Retractions from airway obstruction, respiratory
  distress
• Scars from lung surgery, trauma

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Looking at related structures

• Skin cyanosis, pallor
• Nails Clubbing
• Spongy nail matrix and nail angle of greater than
  160 degrees
• Associated with congenital heart disease

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AP DiameterAnterior Posterior Diameter

• The diameter of the chest from front to back
  should half the width of the chest.
• AP-Transverse/Lateral diameter 12
• Transverse/Lateral should twice as wide as front
  to back
• Barrel chest emphesyma pts (alveoli lost its
  eleasticity so lung tissue does not recoil back
  to normal
• COPD / Emphysema classically produces the "Barrel
  Chest Deformity" Lungs are overinflated, and
  pushing the chest wall out
• Pectus carinatum (Pigeon chest) sternum
  protrudes out beyond the front of the abdomen
  may be related to Rickkets
• Pectus excavatum (funnel chest) sternum pushed
  in depressed on all or part of the sternum

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Normal Breath Sounds

• Bronchial over trachea
• Bronchiovescular over main bronchi
• Vesicular over lesser bronchi, bronchioles, and
  lobes

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Adventitious/AbnormalBreath SoundsNote whether
the sound occur during inhalation or exhalation,
or both.

• Discontinuous sounds
• Crackles (Rales)
• Fine
• Course
• Atelectic crackles
• Pleural friction rub

• Continuous sounds
• Wheezes
• Rhonchi

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Wheeze RhonchiContinuous Sound

• Wheeze
• high-pitched musical sounds heard first when a
  patient exhales
• Partial blockage in airflow
• Severe blockage wheezes also heard when patient
  inhales
• Asthma, CHF, or foreign body obstruction, tumors
• Rhonchi
• low pitched snoring, rattling sound
• heard primarily when the pt exhales
• may also be heard on inhalation
• disappears with coughing
• Uncleared secretions, bronchitis, pneumonia,

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Crackles Discontinuous Sound

• Crackles (Rales) -Caused by collapsed or
  fluid-filled alveoli popping open.
• FINE Crackles
• usually heard in the lung bases
• CHF, Pneumonia, restrictive diseases pulm
  fibrosis, asbestosis, atelectasis (early CHF)
• COURSE Crackles
• during inhalation and may be present in
  exhalation
• Sounds like bubbling or gurgling as air moves
  through secretions in the larger airways
• COPD, pulm edema

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Crackles Discontinuous Sound

• Crackles (Rales) -Caused by collapsed or
  fluid-filled alveoli popping open.
• Atelectic crackles
• common in elderly, disappears after several deep
  breaths
• Pleural friction rub pericarditis
• fluid in the pericardial space due to inflamed
  pleura
• pain on deep inspiration.

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Pulmonary Edema

• Accumulation of fluid in the air sacks (aveoli)
  of the lungs

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Abnormal Breath Sounds

• Diminished breath sounds
• Obese, muscular chest wall
• poor inspiratory effort
• pleural effusion
• Absent breath sounds
• Missing lung/lobe
• airway obstruction, pneumothorax

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Lungs - Palpation

• Crepitus SQ air pockets abnormal
• Indicates subcutaneous air in the chest
• Feels like puffed rice cereal crackling under the
  skin and indicates air is leaking from the
  airways or lungs due to chest tube or open wound
• Tactile fremitus increased fluid accumulation
  abnormal
• A palpable vibration that is caused by the
  transmission of air through the broncho pulmunary
  system
• Decreased fremitus over areas where pleural
  fluid collects (effusion, and pneumothorax,
  atelectasis, emphysema)
• Increased fremitus abnormally seen in areas in
  which alveoli are filled with fluid and exudate,
  occurs with consolidation of lung tissue
  (pneumonia). You will feel more vibration.

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Objective Data

• Respiratory
• Rate 18 resp/min
• Depth deep, even, shallow
• Effort labored, unlabored
• Breath Sounds
• Describe clear, rhonchi, inspiratory/expiratory
  wheezes, crackles
• Location all lobes, throughout lung fields, LLL,
  RUL/RML, lower lobes bilat.
• Cough present/not present
• Describe productive, moist, nonproductive
• Sputum large amount, thick yellow moderate pink
  frothy sputum, sml. Amt. thin clear sputum.

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Interventions

• Position, Turn, Cough, Deep breathe
• O2 Method nc, venti mask, rebreathing mask
• Flow rate 2L/min 3l/min
• Humidity yes/no
• Pulse Oximeter continuous, spot monitoring
• Incentive Spirometer in use, n/a
• Time used 10 am, 11 am, 1 pm, 3 pm
• Volume 500 cc, 500 cc, 600 cc, 800 cc
• Oropharyngeal Suctioning Describe- moderate
  amount thick tan secretions
• Med List Albuterol inhaler, Prednisone,
  Theophylline

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Abdomen

• Sounds, masses, tenderness
• Divide into four quadrants RUQ, RLQ, LUQ, LLQ
• Inspect then auscultate
• Bowel sounds absent, hypoactive, hyperactive
• Listen continuously for 5 minutes to determine
  absence
• Palpate and/or percuss after listening
• Abdomen should be soft, non-tender, non-distended

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Abdomen

• RUQ liver, gallbladder, duodenum, head of the
  pancreas, hepatic flexure of colon, ascending
  /transverse colon, right kidney
• LUQ stomach, spleen, body of pancreas, left
  kidney, splenic flexure of colon,
  transverse/descending colon
• RLQ cecum, appendix, right ovary, tube, ureter,
  and spermatic cord
• Midline aorta, uterus, bladder
• Epigastric, umbilical, suprapubic

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Different Sequence of Assessment

• Inspect
• Auscultate
• Percuss
• Palpate
• Procedure
• Have patient empty bladder
• Position patient supine with knees slightly
  flexed

• Note the abdominal shape and contour.
• The abdomen should be flat to rounded in people
  of average weight.
• A protruding abdomen may be due to obesity,
  pregnancy, ascites, or abdominal distention.
• A slender person may have a slightly concave
  abdomen

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Abdomen - Inspection

• Lesions benign, scars from sx or trauma,
  striae, etc.
•  Distention - can be from fluid, air, mass, or
  obstruction
•  Pulsations - or movement of abdominal wall from
  peristalsis, pulsations and respiratory movement
• Peristalsis usually cant be seen. If
  seen, slight wavelike motions.
• Visible rippling waves may indicate bowel
  obstruction -reported immediately.
• In thin pts, abdominal aortic pulsations may be
  seen in the epigastric area.
• Marked pulsations may indicate HTN, Aortic
  insuff, AAA, or other condition causing widening
  pulse pressure (see next slide)

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Aneurysm

• Note vascular sounds presence of bruits over
  aorta, renal, iliac, femoral
• Normally no bruits noted
• Abdominal aortic aneurysm surg emerg.-tx immed
  to prevent hemorrhage, shock, and death
• If you see bounding pulsation on abd wall, feel
  for pulsations, and measure (greater than 6 cm-
  most likely aneurysm) report.

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Auscultation of Bowel Sounds

• Absent
• no BS for 5 min
• Hypoactive
• less than 5/min
• Active
• 5-30 per min
• Hyperactive
• gt 30 /min

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Abdomen - procedure

• BOWEL SOUNDS
• VENOUS HUMS
• RENAL BRUITS
• INGUINAL BRUITS
• Use diaphragm of stethoscope lightly on skin to
  prevent stimulating bowel sounds
• Start in RLQ (BS often present here) then proceed
  all four quadrants
• Listen for 3-5 minutes
• Note character and frequency of BS

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Bowel Sounds

• Normal BS are high-pitched, gurgling noises
  caused be air mixing with fluid during
  peristalsis. The noises vary in frequency and
  pitch, and intensity. They are loudest before
  meal times. Normal BS 5-30 per minute
• Borborygmus, or stomach growling are the loud,
  gurgling, splashing bowel sound heard over the
  large intesting as gas passes through it.
• Hyperactive BS - gt 30 /min loud, high pitch,
  tinkling that occur frequently may occur with
  diarrhea, constipation, and laxative use
• Hypoactive lt 5 per min - occur infrequently
  assoc. with bowel obstruction, ileus,
  peritonitis, and indicate diminished peristalsis.
  (paralytic ileus, use of narc meds can
  decrease peristalsis)
• Absent, no BS for 5 minutes.
• Be sure to allow enough time for listing in each
  quadrant before you decide that bowel sounds are
  absent. If NGT to suction, turn off suction as to
  not obscure or mimic sounds

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Percussion

•   To assess
• -Density of abdominal contents
• -Locate organs
• -Screen for abnormal fluid or masses
•  
•   Tympany predominantly over the abdomen
  gas-filled
•  
•   Dull over organs in the abdominal cavity
  (liver, spleen)
• CVA tenderness Costovertebral AngleCVA
  tenderness positive in pyelonephritis

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Abdomen - Palpate

• Palpate all four quadrants
• To check for muscle resistance or rigidity
  masses, fluid, tenderness.
• To palpate, put finger of one hand close together
  and make gentle rotating movements as you depress
  ½ inch (1.3 cm) Light palpation depress 1
  cmRelaxation Tenderness Masses
•    Palpate areas of pain and tenderness last
•   Normal the abd should be soft and nontender.
  As you palpate, note any
• Abnormal findings tenderness, masses, and
  rigidity

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Palpation

• Light Palpation
• TENDERNESS, MASSES, RIGIDITY

• Deep Palpation
• Deep palpation - depress 5-8 cm thats about 2-3
  inches.
• In obese, patient, put one hand over the other
  and push down.
• Palpate the entire abd on a clockwise direction
  and not any Tenderness  Masses Enlarged
  organs

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Normally Palpable Structures

• Know what is underneath so you can determine what
  can be expected from normal to abnormal
• Ex. suprapubic distention, full bladder or
  tumor?
• Sigmoid colon, stool can be palpated there
• Liver should not be able to palpate liver way
  below the rib enlarged

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Rebound Tenderness

• Use when found abdominal pain or tenderness
• Hold hand at 90 deg angle push slowly deeply
• Lift hand quickly
• Norm. response is no pain on release of pressure
• Perform at end

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ABDOMEN (summary)

• INSPECT-SKIN, PULSATION
• AUSCULTATE FOR BOWEL SOUNDS IN 4 QUADRANTS FOR
  2-5 MIN DETERMINE IF AUDIBLE, ABSENT,
  HYPOACTIVE, HYPERACTIVE
• PERCUSS FOR TYMPANY LIVER DULLNESS
• PALPATE LIGHTLY FOR TENDERNESS, MASSES, RIGIDITY

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References

• ASSESSMENT OF HEAD NECK http//e-courses.cerrito
  s.edu/rsantiago/My20Webs/ASSESSMENT20OF20HEAD2
  020NECK_SP2004.ppt
• Health History and Physical Assessment
  http//e-courses.cerritos.edu/rsantiago/My20Webs/
  PowerPoint20Presentations.htm
• Physical Assessment http//webteach.mc.uky.edu/nur
  sing/nur869/webquests/lab1/Presentationphysical20
  assessment.ppt

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References

• Rachel S. Natividad, RN,MSN Assessment of the
  Abdomen http//e-courses.cerritos.edu/rsantiago/My
  20Webs/ASSESSMENT20OF20THE20ABDOMEN20N212_n25
  120SP04.ppt
• Rachel S. Natividad, RN,MSN Assessment of the
  Heart, Great vessels of the neck, and Peripheral
  Vascular system http//e-courses.cerritos.edu/rsan
  tiago/My20Webs/Cardiovascular20Assessment20_N21
  2_N25120SP04.ppt
• Rachel S. Natividad, RN, MSNThe Respiratory
  System, Thorax and Lungs
• http//e-courses.cerritos.edu/rsantiago/My20Webs/
  Resp20Assess20N212_25120SP04.ppt